Quality Account 2020/21 - Our commitment to quality excellence - FINAL v1.0 - Moorfields Eye Hospital
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Quality Account 2020/21 Our commitment to quality excellence FINAL v1.0
Contents
Section/Chapter Page
Part 1: Statement on Quality
1.1 Statement on quality from the Chief Executive 3
1.2 Introduction to the Quality Account 2020/21 4
1.3 Moorfields Eye Hospital’s approach to improving quality 4
Part 2: Priorities for improvement and statements of assurance from the Board
2.1 Progress with 2020/21 quality priorities 6
2.2 Core clinical outcomes 18
2.3 Performance against key local indicators in 2020/21 21
2.4 Performance against 2020/21 national performance and core indicators 24
- Referral to treatment (18 weeks) performance
- Data quality
- Readmission
- Family and friends test for patients
- Family and friends test for staff
- Venous Thrombo Embolism (VTE)
- Patient safety incidents (PSIs) including duty of candour (DOC) and learning from
deaths
2.5 Statements of assurance from the Board 41
2.6 Priorities for improvement for 2021/22 51
2.7 Key indicators for 2021/22 55
Part 3: Other information including a statement from our commissioners
- Statement from commissioners 61
- Statement of directors’ responsibilities 62
- Limited assurance statement from external auditors 64
Part 1: Statement on quality 1.1 Statement on quality from the Chief Executive This year has been one of tremendous challenge due to the Covid-19 pandemic; probably the most challenging in the history of the NHS. Moorfields Eye Hospital NHS Foundation Trust (the trust) has risen to this challenge amazingly well and has been resilient in the face of huge adversity. We were able to continue to operate many services. Our A&E has been open 24/7 every day and our teams have been focused on prioritising care for those most at risk of sight loss or serious disease. Our staff and services have shown great innovation by changing access through the use of technology, which provides remote access routes. I have no doubt this has provided care for thousands of patients who might not otherwise have been able to access it, and these services will remain in use going forwards. During all of this, our infection control team has maintained very high safety standards, helping manage accces to Moorfields facilities whilst ensuring social distancing and the use of face masks helped to limit the spread of Covid-19. As is often the case through very challenging circumstances, the pandemic has driven rapid change. As mentioned above, thousands of patients have now been seen remotely thanks to advances in technology. Moorfields is leading the the way across ophthalmology and the NHS, driving changes to our clinical pathways. We have set up diagnostic hubs across our network which offer rapid access to diagnostics for large numbers of patients every day, in a way that until very recently was not even envisaged. Our ambition is combining fast and smooth treatment with excellent outcomes and a high quality experience, which we are monitoring through our quality priorities. Throughout 2020/21 we have once again achieved excellent clinical outcomes. An amazing achievement given the pandemic. Also, the integrity of our quality governance has been maintained which provides the organistion with solid assurance over our three key quality areas of patient safety, clinical effectiveness and patient experience. Our quality account reflects our quality performance in 2020/21. Overall we have made good progress with many of our indicators. Others have performed less well and we will restore performance in those areas as we continue to recover from the pandemic. Very importantly we remain committed to being a learning organisation. This is demonstrated very clearly through our learning from the pandemic and how this has very rapidly translated into improvements in clinical care. None of this would have been possible without the dedicated and committed staff of Moorfields, of whom I am so very proud of. More than 150 of our staff were redeployed during the first and second wave, and they have served (and in some cases continue to serve) the wider health community. Staff well-being is a top priority at Moorfields and it is only through caring for our staff that we can continue to provide such excellent ophthalmic care for our patients. In terms of the future, we look to refreshing our trust strategy with a clear focus on excellence, equity, and kindness as the NHS continues to manage the pandemic and its impact. David Probert Chief Executive Page | 3
1.2 Introduction to the Quality Account 2020/21
Quality accounts help NHS trusts improve public accountability for the quality of care they
provide. The Quality Account is a key mechanism to provide demonstrable evidence of
improving the quality of a trust’s services. The Quality Account also describes the organisation’s
quality priorities and aims for the coming year.
The Quality Account also incorporates the relevant requirements of the Quality Accounts
Regulations as well as those of NHS Improvement’s (NHSI) additional reporting requirements.
The purpose of the account is to:
• promote quality improvement across the NHS.
• increase public accountability.
• enable the trust to review its services.
• demonstrate what improvements are planned.
• respond and involve external stakeholders to gain their feedback, which includes patients
and the public.
Our Quality Account provides an appraisal of achievements against our priorities and goals set
for 2020/21.
At Moorfields, the quality of the services provided has always been at the heart of decisions
taken by the Board. Our quality strategy draws on everyone to make a difference, and be part
of Moorfields journey from Good to Outstanding. Underpinned by the three key drivers for quality,
the trust’s quality structures create robust arrangements for driving improvement and providing
a clear and accountable process for scrutiny and assurance for delivery of the Quality Account.
1.3 Moorfields Eye Hospital’s approach to improving quality
At Moorfields, our core belief is ‘people’s sight matters’ and our purpose is ‘working together to
discover, develop and deliver the best eye care’. We define quality as ‘providing safe care,
outstanding outcomes, and positive experience and involvement for all our patients’.
Quality is our core philosophy, and at the heart of every decision we make. In a time of rapid
technological advances, Moorfields’ expertise, reputation and network places us in a unique
position to lead the way in delivering quality eye care. We want to harness all of our skills and
enthusiasm for learning and sharing to deliver excellent clinical care and world-leading research,
so that we deliver the outstanding quality our patients deserve, and to truly live up to our name
as a world-leading organisation.
Our priorities are consistent with the objectives set out in our quality strategy and form an
important part of its implementation. It is both ambitious and aspirational by design. Throughout
the document, Moorfields sets out its priorities under the three well established headings of
Patient Safety, Patient Experience and Clinical Effectiveness.
2020/21 has been dominated by the Covid-19 pandemic. Much time has been devoted to (and
continues to be in 2021/22) the on-going risk assessment and stratification of patients to ensure
that they are seen in order of clinical priority. Covid-19 has also had an impact on the majority
of the KPIs, both locally and nationally within this report. This includes the 2021/22 quality
priorities where the organisation may need to change its priorities as a result of the continuing
pandemic and our recovery response. Moorfields will continue following advice and guidance
from NHS Improvement and NHS England to ensure patients continue to receive high quality
Page | 4care. NHS Improvement and NHS England has confirmed that NHS providers are no longer expected to obtain assurance from their external auditor on their quality account/quality report for 2020/21. Also, there has been no requirement to consider indicators or metrics for external assurance or assurance through our governors for 2021/22. The Quality and Safety Committee on behalf of the Board takes responsibility for the overview and scrutinty of the development and delivery of the Quality Account and quality priorities. For information or to provide feedback on this quality account, please email Ian Tombleson, Director of Quality and Safety at i.tombleson@nhs.net. Page | 5
Part 2: Priorities for improvement and statements of assurance from
the Board
2.1 Progress with 2020/21 priorities
We set ambitious priorities to drive high quality care and respond to the challenge of meeting
the health needs of our diverse community. Moorfields identified six priority areas for 2020/21.
We developed these with patients, staff, and host commissioners, NHS Islington Clinical
Commissioning group, and supported by the membership council. The trust’s governors have
also considered the contents of the quality report and were supportive of the quality priorities.
The rationale behind the priorities was based on the progress made with the 2019/20 priorities
as well as other key drivers such as staff and patient feedback. The quality priorities were
approved by the trust board. The identified six priorities were based on three domains of quality:
Patient Safety, Clinical Effectiveness and Patient Experience.
Having set ambitious targets, the trust has demonstrated progress across them all. In some
areas, full achievement has not always been possible and this has been explained in the text.
As a result, some priorities will continue into 2021/22; please see a list of 2021/22 priorities
from page 53 onwards.
Summary of the 2020/21 quality priorities:
Domain No Description Priority continued
from 2019/2020
To support safer care for patients
undergoing invasive procedures through
1 developing LocSSIPs according to
Continued from 2019/2020
National recommendations (NatSSIPs).
Patient Safety
Continue improving systems and
2 processes through a learning framework Continued from 2019/2020
to share and embed learning.
3a: Continue providing reasonable
adjustments to deliver person centred
care by improving the use of helping
hands stickers for vulnerable patients
with additional support needs.
3 3b: Improve patient care by embedding
New
Clinical the use of the pain assessment tool for
Effectiveness all patients who are known to have
cognitive impairment and communication
difficulties.
Improve staff access to health and
wellbeing initiatives and increase the
4 New
number of staff using Moorfields Health
& Wellbeing initiatives.
Improving the experience of our patients
5 through improved customer care - Pilot New
Patient
at Private division.
Experience Improve overall patient call response
6 time to improve patient experience.
Continued from 2019/2020
Page | 6Quality Priorities for Improvement in 2020/21
Quality Domain: Patient Safety
Priority 1: To support safer care for patients undergoing invasive procedures through
developing LocSSIPs according to National recommendations (NatSSIPs).
Priority Lead: Andy Dwyer/Divisions
Our priority for 1.1 Undertake a review of the list of invasive procedures compiled in
2020/21 is to: 2019/20, in conjunction with clinical divisions and clinical
services, to ensure that it is compliant with all NatSSIPs. This will
To support safer care include identification of relevant LocSSIPs and their associated
for patients LocSSIPs owners (Q1).
undergoing invasive 1.2 Complete a review of the abbreviated surgical safety checklist,
which is used outside the theatre environment, to ensure that it
procedures through
is compliant with NatSSIPs (Q1).
developing 1.3 Implement the revised abbreviated surgical safety checklist,
LOCSSIPs according where amendments have been made (Q2).
to National 1.4 Audit/re-audit of all LocSSIPs to assess compliancy to be
recommendations undertaken (Q2-Q4) and be included in the annual audit planner.
(NATSSIPs). 1.5 Annual activity summary and thematic review of audit findings to
be completed, the outcome of which will inform the annual work
plan 2021/22.
Background
An initial review of NatSSIPs and LocSSIPs in 2019 identified there was likely to be a
number of local invasive procedures across the trust that would require review and
standardisation. One of these included the delivery and standardisation of Intravitreal
Injections where an initial trust wide audit undertaken in 2019 had identified variability across
all sites.
What have we achieved to date?
1.1 Review list of invasive procedures
A list of 1,867 procedures combining all procedures undertaken across all sites (and outside
theatre settings) was reviewed and was shortlisted to 33 procedures considered to be
invasive procedures against national standards.
These 33 were grouped into categories of: Injections (7); Minor Ops (6); Outpatient Laser
(6); Refractive Laser (10); and Other (4). A working group for each of the 5 categories is
being created to review the checking processes within all relevant procedures. There has
been some delay to their establishement due to Covid-19.
1.2 Complete a review of the WHO Surgical Safety Checklist to ensure compliance with
NatSSIPs
An initial review of the Surgical Safety Checklist identified that the process and checklist was
compliant with NatSSIPs. A separate quality improvement project at City Road undertaken
by Quality Partners examined ways to improve compliance with the team brief and debrief in
theatres, and focused on empowering staff to improve their communication skills. Focus
groups and human factors simulation training was developed for theatre staff to attend.
1.3 implement the revised amendments to Surgical Safety Checklist
An initial focus has been placed on review and standardisation of the processes for
Intravitreal Injections as a pilot. A working group was established in Q2 including advanced
nurse practitioners from Moorfields North, South and City Road divisions, a medical and
pharmacy lead, and members of the central quality team. The working group assessed the
Page | 7patient pathway for Intravitreal Injections and the use of paper and electronic health records.
An agreed style of checklist was of a similar design to the sign in, time out, and sign out
steps of the WHO Surgical Safety Checklist and will form the basis for the development of
other checklist developments across the trust. Essential data and the wording of safety
measures were agreed, and an accompanying standard operating procedure (SOP) was
developed in Q3. The SOP was agreed at Clinical Governance Committee and ratified and
published in Q4. Once embedded, an audit of compliance against the agreed processes
within the SOP will take place.
1.4 Audit/re-audit of all LocSSIPs
An initial audit of Intravitreal Injection was completed in 2019 to determine gaps in the
procedure. In 2021/22, after the SOP processes have been embedded, a re-audit of the
Intravitreal Injection process and use of the checklist will be undertaken.The agreed
Intravitreal Injection checklist design will form the blueprint for the development of checklists
required within the other categories of invasive procedures.
1.5 Annual activity summary and thematic review of audit findings in 2021-22.
A review of findings from the development and audit of LocSSIP procedures will be
undertaken in 2021/22 and these audits will be included in trust wide audit planner.
What are the gaps in delivery, if any?
Good progress has been made on this despite the pandemic. All divisions have been
included in discussions and review of current surgical checklists, and further support and
engagement is needed to ensure standardisation of surgical procedures across all sites.
What will we do in 2021-22 to continue with progress?
Using the outcome of the pilot, 2021/22 will see the development of working groups for each
of the grouped categories of relevant surgical safety procedures to oversee the development
of standardised checklists within each.
Quality Domain: Patient Safety
Priority 2: Continue improving systems and processes through a learning framework to
share and embed learning
Priority Lead: Julie Nott/Divisions
Our priority for 2.1 Launch the learning framework across the organisation, for
2020/21 is to : implementation by all staff at all locations (Q1).
2.2 Develop the learning and improvement following events (LIFE)
Continue improving hub on the intranet, as a repository for shared learning and learning
systems and materials (LIFE hub) (Q1/Q2).
processes through a 2.3 Ensure that all clinical divisions routinely produce quarterly
learning framework newsletters (Q1-Q4).
2 .4 Continue the annual programme of executive (listening, learning
to share and embed
and sharing) walkabouts and develop the ways in which thematic
learning feedback can be shared across the organisation (Q1-Q4).
Background
Moorfields has a number of well established ways it identifies and shares learning, including
weekly Serious Incident (SI) panels and monthly divisional quality forums and safety
newsletters. We will continue to ensure that ways to learn from patient safety incidents and
other safety events are clearly defined and embedded in systems and processes, and
Page | 8clearly communicated to staff. This priority has been a continuation from last year to ensure
we develop systems to capture and disseminate learning across our organisation.
What have we achieved to date?
During the year, good progress was made to formalise the ways by which learning is shared
throughout the organisation. Below is a summary of the achievements, recognising that it
has not possible to embed processes as robustly as originally anticipated as a consequence
of the pandemic:
A Learning Framework (LF) has been developed, which describes the opportunities
for all staff, across the whole network and in all locations, to learn from events that
may have resulted in harm, as well as those events that have gone well. This is
available on the trust intranet.
LIFEhub, which is a central repository on the trust’s intranet (eyeQ) for sharing
learning, is now live and is in the process of being populated with relevant
information. The central quality team and Moorfields UAE have continued to
produce quarterly newsletters. All divisions share regular newsletters with their
teams, but it is noted that the routine production of these has been impacted by the
pandemic, in particular the redeployment of staff.
A dedicated bulletin, LIFEline, is routinely produced to support the shared learning
associated with all serious incident and never event investigations. Divisions and
clinical services cascade these to their teams. The full investigation reports are
shared at SI panel, clinical governance committee and at relevant divisional quality
forums.
SI panel routinely receives and reviews the findings and shared learning from all
root cause analysis (RCA) investigations and a number of after action review (AAR)
findings. This means that the findings translate to shared learning across the
divisions, with adaptations to ensure applicability.
SI panel produces an escalation summary for bi-monthly clinical governance
committee, highlighting key learning, areas of concern and a summary of activity.
The introduction of daily team safety huddles provided the opportunity for specific,
team-based learning to be shared quickly and easily.
Internal audit undertook a review of methods and feedback mechanisms by which
we gather feedback from patients, learn lessons from feedback and evaluate the
effectiveness of their responses. The rating received was significant assurance with
minor improvement opportunities.
What are the gaps in delivery, if any?
Good progress has been made with this priority and both the central team and the
divisions will monitor progress through quality forums.
There was a hiatus in the production of divisional newsletters as a consequence of
the pandemic, although quality forums continued to function when it was possible to
do so.
A formal launch of the Learning Framework will take place in 2021/22 and further
development and promotion of LIFEhub is required, to ensure that it is most
effective.
Page | 9 The last scheduled executive (listening, learning and sharing) walkabout took place
in February 2020, with the programme suspended because of the pandemic. The
programme recommenced in Q1 2021/22.
What will we do in 2021-22 to continue with progress?
LIFEhub will continue to be populated with shared learning, to ensure that it is
readily accessible by staff.
In 2021/22, there will be a formal launch of LIFEhub and the Learning Framework.
The formal programme of executive walkabouts recommenced in 2021/22.
Quality Domain: Clinical Effectiveness
Priority 3a: Further provision of reasonable adjustments to deliver person centred care by
improving the use of helping hands stickers for vulnerable patients.
Priority Lead: Lucy Howe/Divisions
Our priority for 20/21 3a.1 An information sticker to record individual need and reasonable
is to : adjustments inside patient records will have been developed and
commissioned by Q2.
Further provision of 3a.2 All networked sites and City Road services will have received
reasonable updated Helping Hands guidance by Q3.
adjustments to 3a.3 The Learning Disability Policy and the Caring for Patients with
deliver person Dementia Policy, and the respective policy summaries, will have
been updated to reflect the new guidance and will be communicated
centred care by
to staff by Q3.
improving the use of 3a.4 Changes to the guidance to be reflected within corporate
helping hands induction, safeguarding champions training, and bespoke learning
stickers for disability and dementia training by Q3.
vulnerable patients 3a.5 All patient records with a new Helping Hands sticker will have
with additional the individual’s support needs and reasonable adjustments recorded
support needs. and clearly identifiable by Q4.
3a.6 An audit to review the use of Helping Hands stickers and the
new guidance will have been completed by Q4
Background
Helping Hands stickers identify patients who need additional assistance or reasonable
adjustments whilst attending Moorfields. Examples of this are patients with sight loss or sight
problems; hearing problems;physical disabilities and mobility impairment; patients with
learning disabilities and/or Autism; patients with Dementia and patients with cognitive
impairment, including stroke, Parkinsons disease and brain injury. We should also note that
there are many services that provide support to aid and support patients, such as our
ECLOs (Eye Clinic Liaison Officers) and our nurse counsellors.
Not all patients within these groups need a Helping Hands sticker, which asks the question:
“What can we do to make things easier/better for you during your visit/stay/appointment?”
Although Helping Hands stickers are used throughout the trust, it is not always obvious why
a sticker has been placed on the front of a patient’s healthcare records, or what is needed to
Page | 10make reasonable adjustments to their care. To support this, an information sticker to record
individual needs and reasonable adjustments will be developed to be placed inside patient
healthcare records. Covid-19 has had some impact on our delivery of this priority, and it has
also changed how Moorfields might identify need and make reasonable adjustments for
patients.
What have we achieved to date?
An information sticker has been developed and is ready to be implemented. Due to
changes in the delivery of clinical services in response to Covid-19, production of the
stickers and implementation has been delayed. The use of the stickers will be
reviewed following the introduction of paperless or paper lite systems in some
departments. Moorfields is now undertaking more virtual appointments with patients
and the types of support and reasonable adjustments required may differ, as well as
how they are identified. How, what and where reasonable adjustments are recorded
will need to be reviewed in 2021/22.
Development of A4 helping hands cards that accompanies paper notes was
successfully piloted by paediatric services but has not translated as effectively into
adult outpatient services due to confidentiality issues and movement to paper lite and
paperless systems.
Guidance has been developed in preparation for implementation, and this will be
reviewed with the introduction of paper lite systems and the development of PAS to
record this information. Our guidance will be reviewed in 2021/22 in light of changes
to the clinical ways of working, for example, virtual appointments.
Training will be adapted accordingly – this has been delayed due to the pandemic -
for the delivery of face-to-face training. Amendments to the e-learning training
packages will be completed in 2021/22. Policies and policy summaries will also be
updated.
As part of the Clinical Audit Plan (CAP) 2020/21, the North Division carried out an
audit to ensure patients with learning disabilities and/or Dementia receive reasonable
adjustments to meet their care needs. The audit objective was to ensure that the
‘Helping Hands’ stickers are used appropriately and placed at the front of the
patient’s health records.
Actions taken to raise staff awareness were:
- Audit findings and learning were shared at Divisional Quality Forums;
- Audit findings and learning were shared at local nursing and admin team
meetings;
- Discussions have taken place with Safeguarding champions.
A re-audit was added to the Clincial Audit Plan 2020/21, however, due to the pandemic, this
audit was postponed and will be undertaken in the next few weeks.
What are the gaps in delivery, if any?
The safeguarding team are committed to delivering this quality prioriy. There have been
challenges in completing all of the planned actions due to Covid-19, redeployment and staff
vacancies within the team.
Not only has Covid-19 impacted on our ability to deliver this priority, but it has changed how
Moorfields might identify need and make reasonable adjustments for patients.
Page | 11What will we do in 2021-22 to continue with progress?
Plans for 2021/22:
Review the quality priority to reflect the introduction of paperless or paper lite
systems in some departments and the virtual appointments with patients. The types
of support and reasonable adjustments required may differ, as well as how they are
identified.
Work closely with PAS team to support ongoing development of helping hands flags.
Quality Domain: Clinical Effectiveness
Priority 3b: Improve patient care by embedding the use of the pain assessment tool for all
patients who are known to have cognitive impairment and communication difficulties
Priority Lead: Mary Masih/Divisions
Our priority for 20/21 3b.1 A roll out plan for the use of the pain assessment tool across
is to : the networked sited and City Road by Q1. The tool was originially
Improve patient care implemented at Moorfields at Bedford following a CQC inspection in
by embedding the 2018.
use of the pain
assessment tool for The plan for rolling out the tool across the trust was planned pre-
all patients who are pandemic and, due to redeployment and a pause in non-urgent
known to have
surgical services, this work was unable to continue as it was difficult
cognitive impairment
and communication to test and pilot the tool.
difficulties.
3b.2 Update the Learning Disability Policy and the Caring for
Patients with Dementia Policy to reflect the new guidance and
communicate to staff via “Moorfield News”, divisional quality forums
and “Safeguarding Newsletter” by Q1.
The Learning Disability and the Caring for Patients with Dementia
policies are due to be reviewed at the end of May 2021 - the Pain
Assessment Tool will be incorporated in the policies.
3b.3 Changes to the guidance to be reflected within bespoke
learning disability and dementia training and regularly delivered to all
staff involved in surgical care pathways to enable them to use the
pain tool to record and respond to individual pain needs in Q1.
This bespoke learning will need to be agreed at the task an finish
group and developed by the safeguarding team. A clear action plan
will be in place to start the roll-out in some areas.
3b.4 Implementation and embedding use of the pain assessment
tool will continue in Q2, Q3.
As mentioned above, due to Covid-19, the implementation and roll
out of the tool was not possible. This work will be reinstated.
Page | 123b.5 An audit to review the use of the pain assessment tool across
the organisation will be undertaken in Q3 and Q4.
The Pain Assessment Tool audit is part of the Clinical Audit Plan
(CAP) 2021/22. This audit was also included in the Clinical Audit
Plan 2020/21, however, due to the unavailability of General
Anaesthetic (GA) beds in response to the pandemic, we were not
able to continue with the audit as there were no patients falling into
this category booked for surgery.
Background
Moorfields does not currently have a generic pain assessment tool for patients with a
cognitive impairment who are unable to communicate their pain to staff. This was highlighted
during the CQC inspection in November 2018, where it was raised that individual pain needs
were not being met in our site at Bedford. To address this, the local team worked closely
with the host trust to improve the care that was being provided for patients who are unable to
communicate their pain needs.
Nationally, there are a number of tools in use: Disdat tool and Abbey pain score. Due to the
complexity of these tools, the trust adapted the Abbey Pain tool and modified it to meet the
needs of patients who attend Moorfields for surgery or treatment. We aim to deliver high
quality care and patient experience, ensuring that pain is assessed and managed
appropriately for patients with a cognitive impairment who lack the ability to communicate.
What have we achieved to date?
A pain tool has been developed by the safeguarding team in conjunction with the
matrons and was presented in September 2019 at the Matron’s forum so that it can
be rolled out across the trust.
A Pain Assessment Tool has been implemented at Moorfields at Bedford.
The Quality partner from the North Division is also working on a reasonable
adjustment flags project which will be piloted at the Barking and Potters Bar sites.
This is a project focusing on improvements needed to improve learning disability
pathways across the networks which the pain assessment tool is part of. Reasonable
adjustment has also been added as an option to form part of the learning element on
the safeguard system.
What are the gaps in delivery, if any?
The progress of this project was affected by the pandemic and will now have to be
relaunched for maximum impact. The role of the safeguarding team will be crucial to the
delivery of this and the communication to staff who regularly care for patients with cognitive
impairment and communication difficulties.
What will we do in 2021-22 to continue with progress?
Produce an action plan for the reintroduction of the tool outling the training,
communication and ongoing support that staff may require.
Design a communication launch for all staff to raise awareness.
Learning Disabilities and Dementia policies will be updated.
Page | 13 Run refresher training sessions on Microsoft Teams at the Matrons forum and for a
wider group, if required.
Audit the use of the tool and make any required changes.
Complete the roll out of the programme to all areas of the trust.
Evaluate the use of the pain tool which will be done after one year by the learning
disability lead.
Quality Domain: Clinical Effectiveness
Priority 4: Improve staff access to health and wellbeing initiatives and the number of staff
using Moorfields Health & Wellbeing initiatives
Priority Lead: Denise O’Meara
Our priority for 4.1 Organising awareness sessions on current health and
2020/21 is to : wellbeing issues such as the mental health, menopause,
pensions,starting in Q1.
Improve staff access 4.2 Explore introducing Health & Wellbeing champions and
to health and Mental Health First Aiders (with clear lines of responsibility) by Q2.
wellbeing initiatives 4.3 Introduce a clear platform/portal that staff can access health
and wellbeing offerings by the end of Q4.
and the number of
4.4 Work towards London Healthy Workplace Award by Q4.
staff using Moorfields
Health & Wellbeing
initiatives.
Background
This priority was developed in response to both national and local focus on improving health
and wellbeing of all staff across NHS organisations. The health and wellbeing of staff is one
of our top priorities, and there is a great emphasis on continuously developing initiatives and
opportunities to ensure staff feel cared for.
The pandemic has presented the opportunity to focus more widely on health and wellbeing
both in Moorfields and across the wider NHS. As a result, a great wealth of resources have
been made available across the network and there is collaborative work and sharing at a
level which has not seen before. The central people.nhs.uk site houses useful tools and
guides as well as access to a range of apps with free subscriptions which had not been
available before, Headspace and Sleepio, for example. As part of the People Committee a
health and wellbeing sub group has been created and will meet for the first time in Q3.
What have we achieved to date?
A Health & Wellbeing Hub has been created on the intranet, creating a space in
which all the health and wellbeing support isstored and easily accessed by staff. The
information is constantly updated and highlighted as part of the EyeQ stories for staff,
and offerings are also referred to in the weekly chief executive briefings.
There are regular webinars on a variety of health related topics run by Thrive LDN
which are advertised and available to staff. These are recorded and can be listened
to when convenient for staff. Topics covered in the ‘Coping well during COVID’
series includes low mood, sleep, working from home and staying well, and finance.
Page | 14 We run Moorfields Wellbeing Wedensday Webinars – topics range from mental
health to finance, and physical wellbeing. These will continue through the coming
year.
Mental health training is provided by ELFT and dates are published on Insight. We
are exploring increasing the Moorfields training we offer.
There has been access to psychotherapists on site and virtually. This is being
offered as part of the NCL health and wellbeing hub and is being reviewed for the
coming year.
Reflection sessions were offered to all staff at the end of the first wave of the
pandemic. These will be offered again in May, along with the on-going programme of
Schwartz rounds.
A new Health and Wellbeing Officer role was appointed at the end of 2020 and is
supporting the delivery of the Health and Wellbeing agenda.
Pastoral care has been introduced, and we are seeking to develop an SLA with a
larger trust in the coming year.
A wellbeing space has been developed at City Road and we will review the space at
networked sites, appreciating some of the constraints with those sites.
A Wellbeing Guardian from the executive team has been appointed.
As a result of the pandemic, we have shown we can work more flexibly.
What are the gaps in delivery if any?
Good progress has been made with this priority. Due to pandemic restrictions, HR teams
have only been able to undertake limited physical activity on site, however, this is improving
as we continue through recovery.
What will we do in 2021-22 to continue with progress?
We are producing objectives that link to the trust’s strategic objectives, along with the NHS
people plan and NHS people promise. There is also a continuing 2021/22 quality priority
which localises health and wellbeing priorities at a divisional level. We will continue to work
with the NHS health and wellbeing networks to understand best practice and learn from
other trusts. The pandemic has also provided an opportunity to share tools and increase the
health and wellbeing offer to staff.
We aim to be visible to staff across the network to ensure that staff are aware of what
support is available and to listen to what they want. We will refine and develop flexible and
agile working approaches started as a result of the pandemic. We will complete our
submission for the start of the London Healthy Workplace Award.
Quality Domain: Patient experience
Priority 5: Improving the experience of our patients through improved customer care –
Commencing a pilot within Moorfields Private division.
Priority Lead: Rachel Bainton/Ian Tombleson
Page | 15Our priority for 5.1 To obtain and analyse baseline data about customer
2020/21 is to: requirements through questionnaires (Q1).
Improve the 5.2 To develop and commence delivery of improvement plans
experience of our (Q2&Q3).
patients through
improved customer 5.3 Evaluation and prepare for roll out across NHS divisions (Q4).
care – Run a pilot at
Moorfields Private
division.
Background
Moorfields has committed to develop a customer care programme to deliver customer care
excellence across the whole organisation. This programme is being developed in
association with the Institute of Customer Services. The decision was made to start the pilot
at Moorfields Private during 2020/2021 and then apply the learning across the NHS
divisions. There has been some impact on this priority due to the pandemic.
What have we achieved to date?
A detailed questionnaire was sent to all customer groups in early 2020 to obtain
feedback about Private patient services at Moorfields. The survey identified clear
customer groups: patients, practice managers, and consultants. Our monthly patient
survey shows high satisfaction from patients at around 98-99% and this is the same
post pandemic. A project timeline identifies three key areas of work including
improvement plans: Communication, Customer Experience and People.
The quality team and a quality improvement manager have been working with the
deputy divisional manager for Access to identify how further improvements can be
made to ensure administrative processes are robust and admin staff feel supported
to deliver high quality and customer care focused services. These improvements will
be developed further in 2021/22 and shared across divisions.
What are the gaps in delivery, if any?
Good progress has been made with this priority in Moorfields Private, and learning from the
private division has been shared with north and south divisions. The Private team has
completed its structural changes, and the focus currently is on hiring the right team and
responding to the changing environment we are facing.
What will we do in 2021-22 to continue with progress?
Moorfields Private is in the process of recruiting to its newly formed posts within its now full
establishment, which will be pivotal in the success of the service and improvements in our
customer care journey.
A quality priority has been developed for 2021/22 to develop an improved customer focus of
the NHS booking team. This priority will be supported by the learning from the customer care
pilot at Moorfields Private. Customer care is forming a strategic priority within the trust
strategy refresh taking place this year. There will be a number of objectives, including
improving sight loss awareness, education, training, and breaking bad news.
Page | 16Quality Domain: Patient experience
Priority 6: Improve overall patient call response time to improve patient experience
Priority Lead: Alex Stamp
Our priority for 6.1 Reduce the average call waiting time that a patient has to
2020/21 is to : wait to speak to Moorfields Eye Hospital via the Booking/Contact
Centre to 2 minutes (currently at 3 minutes) by Q3.
Improve overall 6.2 Reduce the frequency with which calls to the booking centre
patient call response are abandoned, from 20% to 15% by Q3.
time to improve 6.3 Increase the number of sites with a local call management
patient experience system in place to six (currently only City Road) by Q4.
6.4 Reduce the volume of calls into the Booking Centre by 5%
through introduction of a Patient Portal by Q4.
Background
Appointments and difficulties reaching Moorfields Eye Hospital via telephone is a recurrent
theme captured through complaints and PALS enquiries. Improving the responsiveness of
our service and the information we give to patients remains a key priority to improve the
quality of our services.
This year has been heavily impacted by the Covid-19 pandemic, which has had a
subsequent effect on our services leading to a pause in elective activity in April 2020 and a
restart in August 2020. This is reflected in the number of calls received by the booking
centre, average waiting times and abandonment frequency. As a result of the pandemic and
managing our response to it, there have been delays in moving forward with a local call
management system and our new Patient Portal.
What have we achieved to date?
6.1 Average call waiting times: Since July 2019 the target was continuously met, with
performance around 1 minute and 46 seconds until March 2020. Moorfields achieved an
exceptional score of responding to calls within 40 seconds from April to June 2020,
which increased in Q3 where average call response time were 3 minutes and 5 seconds.
However, as the Covid-19 second wave progressed, we saw a marked decrease in
performance within the call centre and call average times regularly failed to meet the
performance targets.
6.2 Abandonment frequency: Our target has been continuously met from July 2019, at
around 13% with an exceptional performance from April-June 2020 where it was 2.7%.
Q3 performance was 15.3%, again close to the target. Unfortunately, as the Covid-19
second wave hit we saw a marked decrease in performance against this standard and
calls were regularly exceeding the 15% abandonment rate.
6.3 There are discussions ongoing regarding the use of our new telephony system which will
support and help organise the number of local call management systems across our
sites. A timeline to support this is being agreed. This has now gone live in St George’s,
Croydon and St Ann’s, with Northwick Park and Ealing next in scope. Within City Road,
we have introduced a call filtering system within the Booking Centre to give patients the
option to access the call queue if they would like.
Page | 176.4 Call volumes: Unfortunately, due to the Covid-19 second wave impact, we have seen an
increase in call volumes rather than a decrease, as patients have been contacting the
team to chase their appointment. At times we have seen 130% of call volumes against
regular business as usual volumes. This has also driven the increase in average call
waiting times and abandonment rates.
6.5 The trust has commissioned DrDoctor as our patient portal system and the system went
live in March 2021 with specific messages to patients. We have now integrated the
system with the trust’s PAS system to allow live, dynamic messaging for patients.
What are the gaps in delivery, if any?
The main driver for gaps in delivery has been the impact of the Covid-19 second wave and
an increase in call volumes due to this. This has had an impact on delivery against these
performance standards.
What will we do in 2021-22 to continue with progress?
In 2021-22 we will:
Continue to track the weekly performance within the Booking Centre in terms of their
performance against the standards for average waiting time, volumes abandoned
and calls waiting over 2 minutes.
Continue with the full rollout of DrDoctor as a patient portal and shifting more patient
communication regarding appointments on to this system.
Develop our local monitoring of call queues at sites across our network.
Begin to develop our customer service offering and training for staff as call volumes
reduce to focus on the quality of the service being offered.
2.2 Core clinical outcomes
Progress in 2020/21
The trust’s performance against the core outcome standards demonstrates excellent clinical
care, with almost every standard being met and many being far exceeded. The complete core
outcome data is tabulated below. Of particular note is the fact that the majority of outcomes are
for all relevant patients across the trust over a full year. This increases the robustness of the
data when compared to sample audits. From September 2020, it became mandatory for all
services to collect electronic patient record (EPR) data only. Most of the services used EPR
throughout 2020 facilitating analysis of larger amounts of data than is possible manually. This
culture change supports more comprehensive data analysis. The EPR system, linked in with
performance and information in many cases, allows generation of core clinical outcomes, at the
‘touch of a button’ for Cataract, Medical Retina, Accident and Emergency, Cornea and Refractive
services. Other services, such as adnexal, are looking to engage with EPR development to make
routine electronic analysis of their clinical outcome data possible too. Due to Covid-19
appointment cancellations, fewer post-operative cataract patients were seen for face-to-face
appointments. Instead, many who had routine cataract surgery were assessed over the
telephone. This meant that less post-operative visions were recorded formally and the patients
who were seen in person were those in whom vision was likely to be less good. Hence, the
slightly lower rate of patients with good vision after cataract surgery, 89%, compared to achieving
the 90% target in previous years.
Page | 18The external diseases service previously circumvented delay in receiving corneal graft success
rates from the NHS blood and transplant services by generating this data internally. This was
possible through the establishment of a specific post-graft follow-up clinic with collaborative
working to set up a database for measuring outcomes on these patients. From this year onwards,
the NHS blood and transplant services (NHSBT) are hoping to provide two-year outcome data
on corneal grafts for specific conditions. Accordingly, this year, we have reported both our own
internally generated data and that which has come from the national report. The internally
generated data on corneal grafts is compared with the national data from two years ago. The
survival of penetrating keratoplasties (PK) at Moorfields at 82% compared to the national rate
from two years ago of 89%. This reflects the fact that Moorfields performs penetrating
keratoplasties on a greater percentage of complex, high-risk for failure cases, in particular
tectonic (maintaining the integrity of the eye) grafts. When tectonic grafts are excluded, corneal
graft survival rate for PKs done for vision is 90%, achieving the target. This hypothesis is backed
up by the national report which only looks at PK survival for keratoconus and so eliminates
tectonic grafts. In both 2019-20 and 2020-21 Both this year and last year, Moorfields’ survival
rates were above those nationally. Whilst our overall DALK corneal graft survival rate exceeded
the national rate from two years ago, we are not sure why we have a higher rejection rate for our
DALK corneal grafts for keratoconus (from the NHSBT report) than expected. We have therefore
reviewed our post-operative protocol for steroid drops after DALK, making it more similar to PK,
which should decrease the rejection rate.
Trust core clinical outcomes 2020/2021
Specialty Metric Standard 2018/9 2019/20 2020/21
Posterior capsule rupture
Cataract 90% 91% 92% 89%
surgery*
Trabeculectomy (glaucoma
Glaucoma >85% 96% 100% 97%
drainage surgery) success
Tube (glaucoma drainage
Glaucoma >90% 92.5% 89% 92.2%
surgery) success
Glaucoma PCR in glaucoma patients*Visual stability after injections
MR >80% 90.3% 92.1% 93.4%
for macular degeneration*
MR PCR in Medical retina pts* 75% 77% 80% 84%
detachment surgery
Success of macular hole
VR >80% 88% 87% 89%
surgery*
VR PCR in vitrectomised eyes*Accuracy LASIK (laser for
Refractive >85% 93.2% 92.3% 94.5%
refractive error) in short sight*
Refractive Loss of vision after LASIK* 85% 95% 98% 93%
Adnexal Entropion surgery success >95% 100% 99% 97%
Adnexal Ectropion surgery success >80% 95% 98% 98%
*Indicators marked with an asterisk are based on a whole year’s data for all relevant
cases trust wide. All other indicators are based on a sample of cases collected over at
least a three-month period during 2020/21.
2.3 Performance against key local indicators for 2020/21
This financial year has seen a focus on responding to the Covid-19 pandemic rather than
business as usual, and as such the key performance indicators that the trust would normally
strive to improve upon have been greatly affected. Whilst the tables on the following pages reflect
a comparison with previous years, that comparison must be viewed with caution as the
operational realities for 2020/21 have been completely different to previous years.
The same can be said when comparing actual performance ofthe targets for 2020/21, all of which
were set without adjustments for the pandemic.
2020/21 key indicators
2017/18 2018/19 2019/20 2020/21 2020/21
INDICATOR SOURCE
RESULT RESULT RESULT Target RESULT
PATIENT EXPERIENCE
New=102
Reduce patient New=94 New=94 New=91
Internal minutes
journey times in Indicator not minutes minutes minutes
(QSIS) Follow-
glaucoma and in use Follow-up= 90 Follow- Follow-
programme up= 85
medical retina minutes up= 101 up= 100
minutes
Improve patient
experience Internal
Indicator not Indicator not
through digital (QSIS) 26.7% 60% 2.7%
in use in use
patient check-in programme
kiosks
Data
completeness Internal
Indicator not
for clinic (QSIS) 46.6% 61.4% 80% 46.6%
in use
journey time programme
(Total)
Data Internal
Indicator not
completeness (QSIS) 59.9% 75.5% 80% 65.7%
in use
for clinic programme
Page | 212017/18 2018/19 2019/20 2020/21 2020/21
INDICATOR SOURCE
RESULT RESULT RESULT Target RESULT
journey time
(Glaucoma)
Data
completeness Internal
Indicator not
for clinic (QSIS) 55.2% 64.6% 80% 53.7%
in use
journey time programme
(MR)
Reduce the %
of patients that Internal
do not attend performance 12.3% 11.6% 11.8% ≤10% 13.4%
(DNA) their first monitoring
appointment
Reduce the %
of patients that
Internal
do not attend Indicator not
performance 10.4% 10.5% ≤10% 14.4%
(DNA) their in use
monitoring
follow up
appointment
% of patients
whose journey
time through Internal
the A&E performance 78.4% 76.6% 75.5% ≥80% 95.1%
department monitoring
was three
hours or less
Theatre Internal
Indicator not
sessions performance 33.8% 32.0% ≤32.4% 53.0%
in use
starting late* monitoring
Theatre Internal
Indicator not
cancellation performance 7.1% 6.8% ≤7.0% 6.5%
in use
rate (overall) monitoring
Theatre
cancellation Internal
Indicator not
rate (non- performance 0.8% 0.76% ≤0.8% 0.49%
in use
medical monitoring
cancellations)
Number of
outpatient
appointments
subject to Internal
hospital performance 2.9% 3.52 4.58% ≤3% 28.5%
initiated monitoring
cancellations
(medical and
non-medical)
SAFETY
% overall
compliance
with equipment Internal
hygiene performance 99.6% 99.5% 99.6% 95% 99.6%
standards monitoring
(cleaning of slit
lamp)
Page | 222017/18 2018/19 2019/20 2020/21 2020/21
INDICATOR SOURCE
RESULT RESULT RESULT Target RESULT
% overall
compliance Internal
with hand performance 95.7% 99% 99.0% ≥95% 99.5%
hygiene monitoring
standards
Number of
reportable Internal
MRSA performance 0 0 0 0 0
bacteraemia monitoring
cases
Number of
Number of
reportable
reportable
clostridium 0 0 0 0 0
clostridium
difficile
difficile cases
cases
Incidence of
presumed Internal
endophthalmitis performance 0.22 0.35 0.12 ≤0.4 0.09
per 1,000 monitoring
cataract cases
Incidence of
presumed
endophthalmitis Internal
per 1,000 performance ≤0.15 0.17 0.08 ≤0.5 0.14
intravitreal monitoring
injections for
AMD
Incidence of
presumed
Internal
endophthalmitis
performance N/A N/A 0.37 ≤1 0
per 1,000
monitoring
Glaucoma
cases
Number of
serious Internal
Incidents (SIs) performance N/A N/A 0 0 2
open after 60 monitoring
days
CLINICAL EFFECTIVENESS
%
Internal
implementation
performance 98.7% 95.7% 100% 95% 97%
of NICE
monitoring
guidance
Posterior
capsule rupture
Internal
rate for cataract
performance 0.99% 1.13% 0.85% ≤1.95% 0.98%
surgery
monitoring
(cataract
service)
Number of Internal
registered performance N/A N/A 1.65% ≤10% 15.8%
clinical audits monitoring
Page | 232017/18 2018/19 2019/20 2020/21 2020/21
INDICATOR SOURCE
RESULT RESULT RESULT Target RESULT
past their
deadline date
Number of Internal
breached performance N/A N/A 6% ≤10% 3%
policies monitoring
* A late start is a session that started more than 15 minutes later than the planned start time.
2.4 Performance against 2020/21 national performance and core indicators
Moorfields reports compliance with NHS Improvement’s requirements, the NHS Constitution
and NHS outcomes framework to the trust board, both as part of monthly Integrated
Performance Reports (IPR) and as specific, issue-focused papers. Moorfields considers that
this data is as described in the sections and tables below because of our internal and external
data checking and validation processes, including audits, but is subject to the caveats raised in
the statement of directors’ responsibilities. An integral part of the IPR process is to identify not
just the performance against the numerical target but to add value to the reporting process by
articulating, through the use of Remedial Action Plans, any corrective actions the trust is taking
to address areas of underperformance.
National performance data
All NHS foundation trusts are required to report performance against a set of core indicators
using data made available to the trust by NHS Digital. Where the required data is made
available by NHS Digital, a comparison has been made with the national average and the
highest and lowest performing trusts. The data published is the most recent reporting period
available on the NHS Digital website and may not reflect the trust’s current position (please
note that the data period refers to the full financial year unless indicated).
National Performance measures
The trust uses comparative data to benchmark performance. The date ranges covered vary for
each measure but the latest available data has been used in the table below:
Average for Highest Lowest
Description of Performance Target Performance applicable performing performing
target 2019/20 2020/21 2020/21 trusts trust trust
(latest) (latest) (latest)
Infection control
MRSA – meeting the
0 0 0 1.03 0 5.47
objective3
Clostridium difficile
year on year 0 0 0 n/a n/a n/a
reduction
Risk assessment of
hospital-related
venous 98.4% 95% 98.5% n/a n/a n/a
thromboembolism
(VTE)1
Waiting Times
Two-week wait from
urgent GP referral for 96.4% 93% 97.8% 88.4% 100% 50.1%
suspected cancer to
Page | 24Average for Highest Lowest
Description of Performance Target Performance applicable performing performing
target 2019/20 2020/21 2020/21 trusts trust trust
(latest) (latest) (latest)
first outpatient
appointment2
Cancer 31-day waits
–diagnosis to first 99.2% 96% 100.0% 95.0% 100.0% 84.2%
treatment2
All 62 days from
urgent GP referral to
85.7% 85% 100.0% 74.3% 100.0% 42.6%
first definitive
treatment2
Four-hour maximum
wait in A&E from
98.5% 95% 99.98% 98.96% 100% 93.4%
arrival admission,
transfer or discharge2
Patients on
incomplete non-
emergency pathways
(yet to start 94.1% 92% 59.7% 56.8% 99.8% 29.2%
treatment) should
have been waiting no
more than 18 weeks2
Maximum 6 week
wait for diagnostic
99.9% 99% 64.4% 62.7% 100.0% 18.0%
procedures2
Other
28-day Emergency
readmission rate
(over 16 years old) – 2.81% 2.64% 1.74% n/a n/a n/a
excluding retinal
detachment
28-day Emergency
readmission rate
(over 16 years old) – 7.09% n/a 5.33% n/a n/a n/a
retinal detachment
only*
28-day readmission
3.33% n/a 0.0% n/a n/a n/a
rate (0-15 years old)
1– National data collection suspended for 20/21
2 – Comparison data from NHS Statistical Work Areas
3 – Comparison data from Model Health System.
Page | 25Referral to treatment (RTT 18 weeks) performance
The ways the trust is required to report RTT18 are:
The incomplete standard is the sole measure of patients’ constitutional right to start
treatment within 18 weeks.
The Number of New Clock Starts.
The admitted and non-admitted operational standards were abolished in 2015/16, but
the trust continues to report this information.
The table below identifies the performance of our full suite of RTT waiting time measures for
the financial year and with a quarterly breakdown.
Year end
Measure Target Q1 Q2 Q3 Q4
2020/21
18-weeks referral to
treatment 92% 65.2% 37.8% 67.5% 69.0% 59.7%
incomplete*
18-weeks referral to
treatment
N/A 49.8% 23.8% 67.5% 67.9% 50.9%
incomplete with
DTA**
18-weeks referral to
≥ 90% 78.3% 37.3% 57.8% 66.5% 55.6%
treatment admitted*
18-weeks referral to
treatment non- ≥ 95% 90.2% 57.0% 52.8% 66.1% 61.8%
admitted*
New RTT periods
(clock starts) all N/A 7,292 18,668 24,702 23,339 74,001
patients***
*As reported in the Integrated Performance Report (IPR) for March 2021
**No longer a reportable KPI and removed from the IPR
***Taken from RTT weekly submission
Performance of the measure of the RTT18 incomplete pathway (the key RTT18 performance
indicator) has decreased due to the effects of the Covid-19 pandemic. Performance has
decreased for all pathways. However, our performance continues to recover across the course
of the year. While there was a dip in performance during the second wave it was not as
significant as the first wave due to the continuing efforts of the services to accommodate
patients while adhering to Covid guidelines. The trust continues to be on course for recovery
of our RTT position. There were also a significant number of checks and balances introduced
that provided assurance that patients from these challenging events were not overlooked or
missed, in addition to our already rigorous patient safety measures.
The measurement and reporting of performance against these targets is subject to a complex
series of rules and guidance published nationally, but the complexity and range of the services
offered at Moorfields means that local policies and interpretations are required, including those
set out in our access policy. Moorfields is also challenged by the geographical distance
between sites, as moving patients to provider care outcomes sooner is often possible, but
patients are reluctant to attend a different site. This particularly affects the smaller sites, as
while some have capacity issues; some have spare capacity that cannot be utilised due to the
above issue. Performance has also been affected by patient’s availability due to Covid
restrictions.
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